Study: Repeat sling surgery should be considered for ongoing incontinence symptoms

A new study by University of Alabama at Birmingham researchers published in the February 2013 issue of Obstetrics and Gynecology found that women who have unsuccessful midurethral sling surgery for stress urinary incontinence and then undergo a second midurethral sling surgery see more quality-of-life symptom improvement than women who undergo only a first procedure.

Stress urinary incontinence, the involuntary leakage of urine with increases in abdominal pressure, affects up to 35 percent of women. A midurethral sling is considered the gold standard for stress urinary incontinence treatment, with more than 103,000 performed annually. The success rates for these procedures at one year post-surgery range from 77 to 90 percent, but that still leaves an estimated 23,600 women having a recurrence of stress urinary incontinence after surgery.

Many women who have an unsuccessful first surgery do not elect to have a second; they move onto other methods of addressing the problem.

The goal of the new UAB study was to assess and compare continence outcomes of women undergoing a first and repeat midurethral sling procedure. It was also designed to compare lower urinary tract symptoms, patient satisfaction and patient impression of improvement of their stress urinary incontinence. Looking at previous small studies, the UAB research team hypothesized that women undergoing a repeat procedure would have outcomes similar to those who experienced a successful procedure the first time.

“The optimal management of recurrent stress urinary incontinence after a midurethral sling procedure is unknown,” said the study’s senior author, Holly E. Richter, Ph.D., M.D., professor of obstetrics and gynecology, holder of the J. Marion Sims Endowed Chair in Obstetrics and Gynecology and director of the UABDivision of Urogynecology and Pelvic Reconstructive Surgery. “There has been little published data on outcomes of repeat midurethral sling procedures for stress urinary incontinence. The largest study before this was a cohort of 77 patients. Despite this limited data, the most common management for recurrent stress urinary incontinence is a repeat midurethral sling procedure.”

The team looked at 1,316 patients who underwent midurethral sling procedures from April 1, 2006, to Dec. 31, 2009, at UAB. Of those patients, 135 (10.2 percent) had undergone prior procedures. Women in the study group were defined as those who had documentation of a prior procedure; women in the control group were defined as those who had no history of having had a prior procedure. Minimum follow-up was 12 months. All eligible patients were mailed six different questionnaires assessing satisfaction and symptoms after surgery, which included questions on measures of satisfaction and patient impression of improvement.

Despite a higher success rate in the group undergoing their first midurethral sling surgery, both groups reported similar improvement in stress urinary incontinence, urgency urinary incontinence and overall distress from urinary symptoms. However, the patients who had repeat operations had significantly better symptom-specific quality-of-life scores.

“This implies that any degree of improvement may be more effective if symptoms are worse at baseline, even if success as defined by the lack of moderately bothersome urinary incontinence is not met,” Richter said. “Also, the prior failed midurethral sling procedure may heighten patients’ perceived appreciation of any symptom improvement after a repeat procedure. This may also help explain why participants reported similar satisfaction rates among groups.”

Richter said these findings will be useful when counseling patients on their options for recurrent stress urinary incontinence.

“Our hope is that this information will be used to educate women considering repeat procedures that while their results may not be the same as in women undergoing a successful primary surgery, they will have significant improvement of symptoms and impact on quality of life,” Richter said. “But they also will need to understand that additional therapies, including behavioral therapies, medication therapy or both, may be necessary to optimize symptom outcomes.”

The UAB paper was led by Alison M. Parden, M.D.; other co-authors included Jonathan L. Gleason, M.D., Victoria Jauk, M.P.H., Rachel Garner, M.D., and Alicia Ballard, M.D., all with the UAB Department of Obstetrics and Gynecology at the time of the study.